Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you applied to RSP before? *

Yes

No

Have you attended RSP previously? *

Yes

No

If yes, did you graduate ?

Yes

No

Birthday *

MM

DD

YYYY

Are you able to work in the U.S? *

Yes

No

Have you served in the U.S. Military? *

Yes

No

If yes, were you honorably discharged ?

Yes

No

Are you eligible for or receiving funding assistance from TANF, SNAP, or other state or federal assistance programs? (This could qualify you for tuition assistance)

Yes

No

Would you be interested in learning more about tuition assistance?

Yes

No

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phlebotomists are responsible for many aspects of patient safety and work in a fast-paced environment wherein much of their shift is spent on their feet. Applicants should be aware of expectations of the job. Shift times vary between facility types. For example, applicants whose goal is to work in a hospital can expect morning shifts (4:00am-12:00pm), evening shifts (11:00am-8:00pm) and/or night shifts (7:00pm-7:00am). An applicant whose goal is to work in a clinic setting can anticipate generally 8:00am-5:00pm shifts. A job shadow is available upon request *

I understand

Yes

No

For RSP classes, students should also anticipate 10 weeks of 4-hour lecture time as well as a minimum of 1 hour of independent learning each night as homework. Is there any other information you would like to provide that might impact your ability to benefit from the program (i.e., physical limitations, dyslexia, attention deficit disorder, etc.)? All information provided is confidential and only used to benefit each applicant. RSP strives to provide as many resources possible to better serve individual situations. *

I understand

Yes

No

I would like to discuss limitations

A non-refundable $45.00 application fee, payable to (Rogue School of Phlebotomy) must accompany your application. An applicant whose check is returned for insufficient funds will be charged an additional fee of ($5.00). Applications are not processed without payment of the application fee. Application fees can be paid by credit/debit card, check or cash. Payments can also be made online at www.roguesp.org *

I will pay by

Online portal on RSP's website

In person cash or check at my interview

I need an invoice emailed to me so I can pay with card

My WorkSource/Equus/PY+/DHS Coach is going to pay

Other

Rogue School of Phlebotomy prohibits discrimination against its customers, employees, and applicants for employment and student applicants on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Rogue School of Phlebotomy *

I understand

Yes

No

Documents due to RSP with application or request for extension: Please bring to interview or email to ajones@roguesp.org. • Proof High School Graduation or GED Completion (this can also be satisfied by an anticipated graduation/ completion date if it will fall before internship placement) • Colored copy of current state issued driver’s license or identification card • 1–3 paragraph Admission Essay detailing interest in Phlebotomy and career goals • Current Resume (minimum 1 page) *

I understand

Yes

No